A Rare Localized Pituitary Stalk Germinoma Presenting in the Third Decade.

We report the case of a 34-year-old male Hispanic patient who presented with an 8-month history of polyuria and decreased libido. An evaluation revealed hypopituitarism, central diabetes insipidus, and a pituitary stalk lesion. No evidence of a neoplasm or an inflammatory/infiltrative disease was found. We treated the patient conservatively with steroid therapy. However, as a result of disease progression, transsphenoidal surgery was performed to obtain tissue for a pathological analysis. Histopathology revealed an intrasellar germinoma, confirmed by immunochemistry. Due to localized disease, radiotherapy was initiated and clinical improvement was noted. This case emphasizes the importance of histopathological analysis; for many physicians, the presentation of a pituitary stalk lesion in a young male adult creates a clinical conundrum. Although the most common etiologies are an inflammatory or secondary neoplasm, the possible presence of an intrasellar neoplasm should not be ruled out. In many cases, imaging characteristics and tumor markers may aid in the diagnosis without the need of an aggressive diagnostic approach. However, in this case, histopathological analysis was the only way to make a correct diagnosis and provide adequate treatment for the patient.

A middle aged woman with isolated ACTH deficiency associated with transient growth hormone deficiency.

Isolated ACTH deficiency (IAD) is a rare entity characterized by secondary adrenal insufficiency with low levels of serum cortisol, decreased production of ACTH, adequate secretion of other pituitary hormones and normal pituitary structure on radioimaging. The prevalence of IAD as a cause of secondary adrenal insufficiency has not been determined. Impairment of growth hormone (GH) secretion has been noted in 20 to 30% of patients with IAD which is normalized after glucocorticoid replacement. We report the case of a 50 years-old female with symptoms and laboratory results suggestive of adrenal insufficiency. Insulin tolerance test confirmed ACTH and growth hormone deficiency. The rest of the anterior pituitary hormones were normal. A pituitary MRI was unremarkable. Glucocorticoid replacement therapy started and eight months afterwards glucagon stimulation test revealed persistent ACTH deficiency but nor- mal growth hormone secretion. IAD can present with nonspecific symptoms and could be potentially fatal in an acute stressful period. Prompt recognition is essential to decrease morbidity and mortality.

Secondary Resistance to dopamine agonist after thirteen months of successful treatment in a 42 years old man.

Prolactinomas are the most common hormone-secreting pituitary tumors and represents approximately 40% of all pituitary adenomas. Pharmacology therapy with dopamine agonists is the mainstay treatment for prolactinomas Usually, patients respond to these drugs with decreased level of the serum prolactin and with time, by tumor shrinkage. Less than 10% of patients with prolactinomas exhibit resistance to the action of dopamine agonists, as defined by the lack of normalization of the serum prolactin levels despite long- term treatment at high doses of these drugs. However secondary resistance to dopamine agonists therapy has also been described in patients who were initially responsive to treatment, either with Cabergoline or Bromocriptine but later develop dopamine agonist resistance, with elevated prolactin levels and sometimes an enlarging tumor volume several years afterwards. We report a case of a male patient with prolactinoma who developed drug resistance 13 months after initial dopamine agonist therapy.

Secondary Resistance to dopamine agonist after thirteen months of successful treatment in a 42 years old man.

Prolactinomas are the most common hormone-secreting pituitary tumors and represents approximately 40% of all pituitary adenomas. Pharmacology therapy with dopamine agonists is the mainstay treatment for prolactinomas. Usually, patients respond to these drugs with decreased level of the serum prolactin and with time, by tumor shrinkage. Less than 10% of patients with prolactinomas exhibit resistance to the action of dopamine agonists, as defined by the lack of normalization of the serum prolactin levels despite long- term treatment at high doses of these drugs. However secondary resistance to dopamine agonists therapy has also been described in patients who were initially responsive to treatment, either with Cabergoline or Bromocriptine but later develop dopamine agonist resistance, with elevated prolactin levels and sometimes an enlarging tumor volume several years afterwards. We report a case of a male patient with prolactinoma who developed drug resistance 13 months after initial dopamine agonist therapy.

Abrupt onset of muscle dysfunction after treatment for Grave's disease: a case report.

Myopathy is a known complication of hypothyroidism, commonly characterized by an elevation in Creatine Kinase (CPK) due to increase capillary permeability proportional to the hypothyroid state. Thyroid hormone is important for the expression of fast myofibrillar proteins in the muscle. In hypothyroidism the expression of these proteins are deficient and there is an increase accumulation of slow myofibrillar proteins. A rapid or abrupt descend in thyroid hormones caused by radioiodine therapy after prolonged hyperthyroidism can lead to local hypothyroid state within the muscle tissue, resulting in CPK elevation and hypothyroid myopathy. Hormone replacement leads to resolution of symptoms and normalization of muscle enzymes serum levels.

Pasteurella multocida: a nightmare for a replaced joint and the challenge to save it.

Pasteurella multocida a small gram-negative coccobacilli is primarily found as normal flora of cats and dogs. These organisms can cause a variety of infections in humans, usually the result of scratches, bites and licks by percutaneous inoculation of the organism. Most cases of septic arthritis involve a cat or dog bite distal to the involved joint without direct penetrating injury to the joint. On scenarios were Pasteurella infection is suspected within a prosthetic joint, aggressive surgical debridement and/or removal of the prosthesis with intravenous antibiotics is recommended. Prosthetic joint infections secondary to animal bites are an extremely rare complication and few cases have been reported in the literature. This is a case report of a patient that suffered a cat's bite of his right prosthetic knee and against all odd was able to save it without surgical intervention.

Just a flare---the Pandora's box approach.

Systemic lupus erythematosus is a chronic inflammatory autoimmune disease characterized by autoantibodies specific for highly conserved nuclear antigens, such as double-stranded DNA, histones and ribonuclear proteins. The course of the disease is unpredictable and nine times more common in females. Among the neurological manifestations of collagen vascular diseases is the most commonly recognized and better studied disease. Central nervous system lupus is a serious and potentially treatable illness presenting as difficult diagnostic challenge. This is a case report of a patient that suffered central nervous system manifestations of severe active lupus. Early recognition of this entity is essential to expedite appropriate to treatment and avoid future complications.

Young female with acromegaloid features and pituitary macroadenoma: what is your diagnosis?

Pseudoacromegaly is a extremely rare condition previously described and characterized by acromegaloid changes, tissue overgrowth, without elevations in insulin-like growth factor or growth hormone as seen in Acromegaly. We present the case of a young female seen initially with acromegaloid features and a pituitary microadenoma. After work-up the patient was diagnosed as insulin-mediated pseudoacromegaly. Only a few cases of pseudoacromegaly has been reported and should always be considered when evaluating patients for acromegaloid features with negative biochemical and hormonal levels.

Hashimoto's encephalopathy: an underdiagnosed clinical entity.

Hashimoto's encephalopathy (HE) is a rarely recognized neurocognitive syndrome that is associated with thyroid autoimmunity. It is more common in women. HE is diagnosed when patients present with nonspecific neurological symptoms associated to elevated titers of antithyroid antibodies and normal or abnormal thyroid function tests. Other neurologic disorders must be ruled out before diagnosis can be established. HE is associated to nonspecific EEG abnormalities as well as elevated cerebrospinal fluid proteins and nonspecific white matter changes. The pathophysiology of HE is unknown but an autoimmune etiology is strongly supported. HE responds to corticosteroids and immunosuppressive therapy, further supporting an autoimmune etiology. A high index of clinical suspicion must be present in order to promptly recognize and treat this disease.

Subacute thyroiditis and dyserythropoesis after influenza vaccination suggesting immune dysregulation.

Subacute thyroiditis (SAT) is an extremely rare complication of influenza vaccination. Several infectious agents have been related with SAT. It is also well known the association between HLA-B35 and the development of SAT. We describe a case of subacute thyroiditis and dyserythropoesis occurring shortly after administration of an influenza vaccine in a 55-year-old man with history of diabetes and psoriasis, family history of autoimmunity without clinical evidence of acute viral infection prior to the onset of symptoms. We propose that, the events occurring in the patient may be explained as result of complex interactions between the individual genetic background and environmental exposure to infectious agents that generated a pro-inflammatory status, where the vaccine was the trigger for the subsequent alterations in thyroid and bone marrow. These findings highlight the importance of immunogenetic factors involved in response to vaccination that is the central theme in the growing field of 'vaccinomics'.

Unusual presentation of primary gastric choriocarcinoma in a 24-year-old female patient.

We report a case of a young female patient presenting with a high serum beta-HCG levels, amenorrhea, nausea and anemia which mimicked pregnancy followed by upper gastrointestinal bleeding. A gastric tumor was shown on endoscopy. Histopathologic evaluation revealed Primary Gastric Choriocarcinoma (PGC). The patient was treated with three cycles of standard nongestational choriocarcinoma chemotherapy. Tumor persistence was evidenced by CT Scans and high serum beta-HCG levels. The patient died approximately six months after diagnosis. Our case report suggest that PGC is a highly aggressive tumor that is often associated with liver and lungs metastasis without evidence of pelvic organ abnormality and is associated with some hormonal effects, such as amenorrhea, anemia, nausea and vomiting mimicking pregnancy in young adult female

Posterior reversible leukoencephalopathy syndrome in hypertensive crisis complicated with seizure.

This is the case of a 32 year-old-male with chronic kidney disease in hemodialysis who presented with uncontrolled blood pressure after admission to the hospital further complicated with seizures. Head CT-Scan revealed hypodensives areas in sub-cortical white matter and parietal-occipital lobes. Posterior reversible leukoencephalopathy syndrome (PRES) was diagnosed by radiologic findings. The underlying cause of PRES was treated with good resolution of hypodensives areas. Good prognostic outcome of PRES depends on prompt recognition and treatment to avoid excessive morbidity and/or mortality.

Uncommon cause of acute abdominal pain at the emergency room: epiploic appendagitis.

This is a case of 49 year-old-female with left lower quadrant pain. Initial diagnosis of acute diverticulitis entertained and treated accordingly. Diagnosis of epiploic appendagitis was done by abdominal CT-Scan. Epiploic appendagitis is commonly misdiagnosed as diverticulitis and appendicitis. Non-invasive studies may lead to early diagnosis avoiding unnecessary hospitalizations, antibiotic therapy and surgical intervention.

Middle aged male with recurrent episodes of confusion, aggressive behavior and loss of consciousness.

We report a case of a 63 years-old-male with repeated bouts of confusion, aggressive behavior, dizziness and loss of consciousness occurring over a year. Such episodes increased in frequency and severity over time and were treated at the Emergency Room with intravenous dextrose solutions. Admitted at San Juan Bautista Medical Center due to severe hypoglycemia. Laboratory evaluation and prolong fasting ruled out an insulinoma or surreptitious administration of insulin or sulfonylurea. A CT scan of the abdomen and pelvis with oral contrast demonstrated a huge intra-abdominal mass invading the mesentery with herniated components laterally in the right lower quadrant. Patient underwent surgical resection of the abdominal mass. Histological description demonstrated a neoplastic pattern. Immunohistochemistry was compatible with an undifferentiated Synovial Sarcoma.

Primary angiosarcoma of the breast in a pre-menopausal woman.

This case report describes the clinical presentation, imaging findings and pathologic features of a rare aggressive breast tumor in a pre-menopausal woman, namely primary angiosarcoma. Recognition of this extremely rare entity is needed to make an early diagnosis, institute early therapy and eventually improve patient's survival.

Hyperthyroidism, hyperfunctioning thyroid nodule, and thyroid cancer in a young female: a rare and unusual coexistence.

The prevalence of concomitant thyroid carcinoma with Grave's disease has been reported to range from 0 to 10%. Many controversies exist in the literature regarding the diagnostic workup and management in these types of patients. We are reporting a case of a 31 year old woman who had Graves' disease, a palpable thyroid nodule, and results from a thyroid scan revealed a "hot" nodule. Interestingly, an ultrasound guided FNA of the "hot" nodule showed papillary thyroid microcarcinoma. Finally, a total thyroidectomy showed multilobar tumor involvement. The diagnostic tools employed to establish the proper management strategy for this patient were based on data in the literature that is full of discrepancies. The fact that Grave's disease occurs concomitantly with thyroid cancer, specifically the papillary type, is an indisputably rare combination. One rare feature on our clinical case was the reported malignancy of a papillary carcinoma within a "hot" nodule which usually is much less that 1%. Many studies describe an increasing incidence of Grave's disease patients with concomitant papillary thyroid carcinoma. One possible explanation for these findings could be improvements in medical technology of screening tools. We propose that, thyroid ultrasonography should be integrated in the diagnostic workup in patients presenting with Graves' disease, especially in those presenting with palpable nodules. Fine needle biopsy should not be restricted to cold nodules.